197608482-10-25-2022-28-AS-RORN-CKRLAH-20221101083511

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 10/18/2022
Date Signed: 10/25/2022 08:24:07 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/04/2022 and conducted by Evaluator Luis Mora

COMPLAINT CONTROL NUMBER: 28-AS-20221004165836

FACILITY NAME:	KINGSLEY MANOR		FACILITY NUMBER:	197608482
ADMINISTRATOR:	LIYON O'QUINN		FACILITY TYPE:	740
ADDRESS:	1055 NORTH KINGSLEY DRIVE		TELEPHONE:	(323) 661-1128
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90029
CAPACITY:	299	CENSUS: 191	DATE:	10/18/2022
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Lyon O’Quinn – Executive Director		TIME COMPLETED:	02:05 PM

ALLEGATION(S):

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Staff do not assist resident with showering

INVESTIGATION FINDINGS:

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*This report supersedes the report dated 10/07/22 to include additional information*

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit to determine the validity of the above-mentioned allegation. LPA met with Lyon O’Quinn (Executive Director) and explained the reason for the visit.

The investigation consisted of the following: LPA obtained copies of the resident and staff rosters, and interviewed Executive Director, Staff 1 - Staff 3 (S1 - S3), and Resident 1 - Resident 8 (R1 - R8).Copies of R1's physician report, admission agreement, care plan meeting, and resident appraisal,

The investigation revealed the following: regarding the allegation "staff do not assist resident with showering”, it is alleged that staff have stopped assisting R1 in transferring from the wheelchair to the shower. R1 has not been able to shower due to the lack of assistance. (CONTINUED TO LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20221004165836

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGSLEY MANOR	FACILITY NUMBER: 197608482
	VISIT DATE: 10/18/2022

NARRATIVE

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Interviews with Executive Director and staff revealed that staff have not assisted R1 in transferring from the wheelchair to the shower since 09/04/22. A staff was injured while assisting R1 in transferring to the shower and thus the facility's Licensed Vocational Nurse (LVN) determined that R1 needs a higher level of care and have suggested to R1 to move to their Skilled Nursing section because they have bigger bathrooms, hoyer lifts and more staff that will be able to assist with showering. Staff are still assisting R1 in transferring to bed and to the toilet. Residents interviewed revealed that 7 out of 8 residents were unable to corroborate the allegation and they stated they do get shower assistance from the staff. The physician report dated 06/10/22 indicates that R1 is ambulatory and has the capacity to self-care in bathing, grooming, feeding self, toileting needs, and managing own cash resources. R1's service plan and appraisal indicate that R1 will receive help with bathing and 1-2 staff will assist using a sliding board. As of 09/04/2022, R1 has not received assistance with showering.

Based on LPA's interviews and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview held and a copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20221004165836

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGSLEY MANOR	FACILITY NUMBER: 197608482
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/19/2022 Section Cited CCR 87464(f)(4)	1 2 3 4 5 6 7	Basic Services. Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement was not met by evidence of:	1 2 3 4 5 6 7	Facility will provide R1 shower assistance as required and additionally will contact R1's physician to have R1 re-assess and submit physician’s report to CCLD by 11/04/2022.
	8 9 10 11 12 13 14	Based on interviews and records reviewed, R1 has not been receiving assistance with showering which poses a potential risk to the health, safety, or personal right of the persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

LIC9099 (FAS) - (06/04)

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